A 67-year-old woman who was recently diagnosed with breast cancer presents with increasing confusion over the past three days. Additionally, over the past week she has been complaining of fatigue, diffuse body aches, poorly localized abdominal pain, and constipation. Which of the following electrolyte abnormalities is the most likely explanation for her symptoms?

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The patient has hypercalcemia of malignancy.Total body calcium levels are tightly regulated by a feedback loop in which parathyroid hormone induces the bones and kidneys to increase serum calcium levels. Conversely, elevated calcium levels inhibit parathyroid hormone release. Vitamin D also plays a role in regulating calcium absorption in the gut.Hypercalcemia is defined as a serum calcium > 10.5 mg/dL.Symptoms of hypercalcemia are varied and include non-focal abdominal pain, constipation, fatigue, diffuse myalgias, anorexia, nausea, and vomiting. Neuropsychiatric manifestations such as depression, anxiety, and hallucinations may also be seen. Severe cases may lead to altered mental status, seizures, and coma.The mnemonic “moans, groans, stones, and psychic overtones,” is useful for remembering hypercalcemia, including the above manifestations as well as a predilection for forming kidney stones.Hypercalcemia has numerous causes, including primary hyperparathyroidism, hyperthyroidism, multiple myeloma, cancer metastatic to bone, granulomatous disease (e.g. sarcoidosis). Medications, such as thiazide diuretics and estrogens, can also raise serum calcium levels. In this elderly patient with a recent diagnosis of breast cancer, bony metastases is a likely cause of hypercalcemia.Hypercalcemia is initially managed with fluids and forced calciuresis. Intravenous saline is needed in severe cases. Intravenous bisphosphonates may be used in hypercalcemia that is due to hyperparathyroidism or a malignancy. Calcitonin can be given to manage hypercalcemia while the bisphosphonates reach therapeutic levels.Unmanaged hypercalcemia may lead to serious complications including neuromuscular manifestations such as weakness or paresthesia, or cardiac arrhythmias secondary to QT interval shortening or heart block.

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Shigella sonnei bacteria resistant Shigella sonnei bacteria resistant to the antibiotic ciprofloxacin sickened 243 people in 32 states and Puerto Rico between May 2014 and February 2015. In the United States, most Shigella is already resistant to the antibiotics ampicillin and trimethoprim/sulfamethoxazole. Because Cipro-resistant Shigella is spreading, CDC recommends doctors use lab tests to determine which antibiotics will effectively treat shigellosis. Doctors and patients should consider carefully whether an infection requires antibiotics at all.

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